Present the case scenario
Allow time for students to think and consolidate their thoughts. Their silence
might mean they are
thinking.

Initiate discussion by asking the Trigger
question:
"How would you like to approach this case?" Allow students to
think loud. Do not interrupt while they are talking.
Simply keep the discussion going by
asking…..
What do you think about the suggestion of (Name of
student)?
Do you agree with ( Name of student
)? What
are your thoughts about this issue , ( Name of student)
? Does
everybody agree with the approach we shall take?

STEP 2

Trigger the discussion on the pathophysiologyEncourage them
to list LEARNING ISSUESEncourage the students to use the blackboard to
illustrate their point. This helps consolidate their
thoughts.

STEP 3

Trigger the discussion back to the patient. Ask for the
Differential Diagnosis.Encourage the listing of the differential
diagnosis based on the mechanism rather than on the disease
entities.
e.g. Mechanism of Edema

STEP 4

Based on the listed differential- trigger the students to ask
for additional
information from the history or PE that will help rule in or rule out their
differential diagnosis

STEP 5

Based from the information gathered, trigger the student to
validate their hypotheses.

Help them focus on the important cues-by asking them to come up
with the list of important cues in the history and
PE

STEP 6

Challenge the students to make the diagnosis Encourage them
to make more LEARNING ISSUES by challenging some other issues not in their list?
E.g. Why is there no ascites here?Ask the student to synthesize the whole
discussion in a few words.

STEP 7

Close the session. Ask students to critic themselves. Comment on
how they could have done better.

Appreciate students
who have done well. Point out politely the weakness of some.(E.g. some who are
quiet) Assign the learning issues by requesting for volunteers who will look
into the matter more in-depth. Volunteers are better than topics being
assigned to students. Agree on the schedule for the next meeting. Advise
students to come back with prepared audiovisuals (sketches or diagrams)
and to provide their classmates a copy. Their sharing should
not be more than 2 minutes. It has to be brief, concise and direct to the
point. They are to provide the source of their reading material as well.

SAMPLE CASE

CLINICAL PRESENTATION

An elderly man presenting with
edema of the lower extremities and back with prominent superficial veins of the
lower limbs, abdominal wall and thoracic wall.

HOW TO OPEN THE
DISCUSSION

How would you like to approach discussing this case?Are
there any other alternative approach that you have in mind? Why do you
prefer to approach this case this way?

HOW TO TRIGGER DISCUSSION ON PATHOPHYSIOLOGY OF EDEMA?

What is Edema? What causes Edema? What are the forces that
causes fluid shifting from the intravascular to interstitial ? Why
don't we list them in the board while we rationalize the mechanisms for each of
the causes?

HOW TO TRIGGER DISCUSSION ON DIAGNOSIS?

Based on the causes of edema, what would your differential
diagnosis be?What other information in the history or PE do you wish to
know?Why did you want to know that information? How will that help in the
diagnosis of this case?Why was there edema of the LE and superficial vein
engorgement of the Abdomen and chest wall but no
ascites?

HOW TO TRIGGER CONSOLIDATION OF THE DISCUSSION

Let us synthesize the case: What were the important critical
points of this case. List them down in the board.Out of these issues, what
cues would you consider strongly to help you make the diagnosis?Based on the
added information from the History and PE, how would you validate your
differential diagnosis?

HOW TO TRIGGER DISCUSSION ON THE ANATOMICAL BASIS

How was the venous blood from the lower half of the body able to
by pass the obstruction in the inferior vena
cava?

Would you expect that deep veins as
well as superficial veins be involved?

What are the superficial veins
involved? Which are the deep veins involved?

Review the tributaries of
the inferior vena cava and the anastomotic connections that would allow the
necessary collateral circulation in this case.

What
specific characteristic of the development of this condition prevented a more
serious or perhaps disastrous crisis to the patient?

Would the
occlusion be more serious at the level of the Lumbar Vertebrae 1 or
higher?

What additional problems would you expect to observe if the
obstruction were at the level of LV-1 ?